Page 11 - GDP - Provider Reimbursement Guide B 2022

Schedule of Benefits and Monthly Payments
ANNUAL MAXIMUM
$1,200
$5.61
Unlimited
$1,5000
Unlimited
Unlimited
Unlimited
Unlimited
$2,500
$1,500
$2,000
$1,200
$1,500
$1,200
$1,500
$1,500
$3,000
Unlimited
$1,800
$1,500
$1,000
$1,250
$1,500.00
$1,200
$1,200
Unlimited
Unlimited
$1,200
Unlimited
SINGLE
$6.00
$8.68
$23.54
$11.13
$11.40
$11.40
$11.40
$11.40
$15.60
$12.00
$5.89
$7.50
$17.23
$12.84
$25.68
$16.66
$9.60
$11.40
$11.80
$11.00
$8.96
$6.14
$12.31
$11.00
$12.29
$18.23
$15.00
$7.96
$8.00
FAMILY OF 2
$11.50
$12.42
$23.54
$19.48
$21.09
$21.09
$21.09
$21.09
$15.60
$12.00
$11.24
$10.00
$17.23
$12.84
$25.68
$16.66
$15.60
$21.09
$23.69
$15.40
$11.20
$11.49
$21.29
$15.40
$14.75
$26.94
$25.00
$12.94
$8.00
MONTHLY CAP RATES
FAMILY OF 3-5
$18.00
$23.54
$30.61
$30.41
$30.41
$30.41
$30.41
$15.60
$12.00
$16.05
$13.50
$17.23
$12.84
$25.68
$16.66
$23.20
$30.41
$34.82
$18.70
$13.44
$16.38
$32.05
$19.80
$37.71
$38.50
$22.60
$8.00
FAMILY OF 6
$33.96
$19.80
$14.56
$20.90
FAMILY OF 7
$37.30
$20.90
$15.68
$22.00
FAMILY OF 8
$40.62
$22.00
$16.80
For a complete list of all Schedule of benefits go to https://providers.goldendentalplans.com
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